GENESIS SECURITY CONSULTING & INCIDENT SURVIVAL
MAIL ENROLLMENT FORM: ADVANCE OPEN SCHEDULED COURSE
For mail registration print and submit this entire form to the address listed below. For parents and employers you may copy this
form to submit multiple student registrations. Please submit only one student per form.
STUDENT LAST NAME:___________________ STUDENT FIRST NAME: ______________________________
PARENT/ EMPLOYER REP. LAST NAME: ________________________ FIRST NAME: _______________________
(Please circle one if student is under 18 years old, or employer is sponsoring student)
CONTACT PHONE: __________________________ COMPANY (If Applies): _____________________________________
MAILING ADDRESS: ___________________________________________________________________________________
CITY: __________________________________________ STATE: _________________ ZIP: ___________________
COURSE NAME: _________________________________ COURSE NUMBER: __________________________________
MAIL PAYMENT
Mail Payment: Seating in this course can only be guaranteed by submitting this form and payment in full in advance. Conformation
of your seating in this course will be made via telephone, email or both. Please do not assume seating until you have received this
conformation.
If you desire to attend this course please make payments to: Gregory V. Dawson/ Genesis-SCI and mail to the following address:
Genesis-SCI
113 Ervin Court
Jacksonville, NC 28546
AGREEMENT
I have read and agree to the conditions and terms listed on the Genesis-SCI website regarding payment, registration, cancellation, and
refunds. I understand that seating in this course can only be secured upon Genesis receiving funds in full, and that placement is based
on a first pay, first seated bases.
Please enroll the named student above in the course requested.
AUTHORIZED AUTHORITY AS CHECKED ABOVE
SIGNATURE : __________________________________________________________